One lesson of the Trump era in Washington is that Republican efforts to repeal and replace Obamacare don’t fare well in sunlight. When these proposals are confined to internal brainstorming sessions and leadership conferences, they do O.K. But, once they are sent out into the world and exposed to proper scrutiny, they tend to shrivel up and die.
The latest G.O.P. effort, a piece of legislation put forward by Senator Lindsey Graham, of South Carolina, and Senator Bill Cassidy, of Louisiana, will hopefully meet this fate. But nobody should take that outcome for granted. Republican senators have until September 30th to enact health-care reform with just fifty-one votes—rather than sixty—so the Party leadership is looking to ram through the Graham-Cassidy bill before the American public realizes how awful it is.
Rushing the bill through this way is about the only way it could pass. Several previous Republican bills were doomed by the Congressional Budget Office, which issued analyses detailing how the plans would cause tens of millions of Americans to lose their health-insurance coverage. By waiting until last week to finalize their bill, Graham and Cassidy didn’t leave the C.B.O. enough time to do a proper scoring before a vote is taken. (On Monday, the C.B.O. said that it would try to produce a limited analysis by early next week.)Get the best of The New Yorker every day, in your in-box.
Despite this cynical maneuver, there is no ambiguity about the terms of the Graham-Cassidy bill. It would roll back the Affordable Care Act’s expansion of Medicaid, which has enabled about fourteen million Americans to obtain health-care coverage. Then it would subject the rest of Medicaid to substantial cuts by converting it to a block-grant program. By targeting the low-paid, the sick, and the infirm, the legislation would create hundreds of billions of dollars in budget savings; these could then be applied to Republican tax cuts aimed primarily at rich households and corporations.
The bill isn’t just a smash-and-grab raid on the poor and nearly poor, though. It would also undermine the insurance exchanges set up under the A.C.A., by stripping away the subsidies for the purchase of policies, abolishing the employer and individual mandates, getting rid of the lifetime caps on health-care outlays, and allowing insurers to force people with preëxisting conditions to pay more.
How much more? According to a new analysis by the Center for American Progress, a liberal think tank, opioid addicts and people with rheumatoid arthritis would face surcharges of more than twenty thousand dollars a year. (That’s in addition to the regular premiums.) For people with serious heart conditions, the surcharge would be more than fifty thousand dollars a year. And for those with metastatic cancer, it would be more than a hundred and forty thousand dollars.
In addition to destroying Obamacare, the bill would hand over to the states some of the money that the A.C.A. raised and let them build their own health-care systems. (This, supposedly, is the “replace” bit of “repeal and replace.”) A few big states, such as California and New York, might try to maintain the current setup, but they would be forced to spend more of their own money to do so. In a blatantly political move, the Graham-Cassidy bill would redirect some of the A.C.A. money to the nineteen Republican-run states that didn’t expand Medicaid, such as Florida, North Carolina, and Texas.
The authors of the bill probably thought that this was a clever wheeze, but it could end up backfiring. Some Republican-run states that did expand Medicaid stand to lose out, including Louisiana, Cassidy’s home. On Monday, Louisiana’s top health official, Rebekah Gee, wrote an open letter to Cassidy saying that his bill could cost the state $3.2 billion in federal funding through 2026, “making Louisiana the 8th biggest loser of those states affected by the Legislation, and by far the poorest and sickest state affected by these cuts.”
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Cassidy won’t abandon his own legislation, but some of his colleagues might. On Tuesday, five Republican governors from states that expanded Medicaid put their names on a letter calling on the Senate not to even consider the Cassidy-Graham bill. They included John Kasich, of Ohio; Brian Sandoval, of Nevada; and Bill Walker, of Alaska. “Given Alaska’s current fiscal challenges, any proposal to shift federal costs to the states would likely result in drastic cuts to our Medicaid program,” Walker told the Fairbanks Daily News-Miner.
In another sign that scrutiny is mounting, the American Medical Association, which represents more than two hundred thousand doctors, and the American Association of Retired Persons, which has thirty-eight million members, also criticized the new bill. The A.M.A. said that the measure “would result in millions of Americans losing their health insurance coverage, destabilize health insurance markets, and decrease access to affordable coverage and care.” The A.A.R.P. added that the legislation would “jeopardize the ability of older Americans and people with pre-existing conditions to stay in their own homes as they age and threaten coverage for individuals in nursing homes.”
There can be no doubt that all of this is true. But, as of Tuesday evening, Rand Paul, of Kentucky, was the only Republican senator to have said definitively that he won’t vote for the bill. (And it’s worth remembering that he’s changed his mind on repeal-and-replace measures before.) Susan Collins, of Maine, has also made critical comments, and most observers believe that she is a more reliable no vote. Attention is once again focussing on Lisa Murkowski, of Alaska, and John McCain, of Arizona. During a dramatic, late-night vote in July, these two senators both sided with Collins to block the G.O.P.’s last serious health-care push.
Conceivably, this could come down to another pressure-filled vote, with the ailing McCain, who is a close friend of Graham, once again center stage. The Cassidy-Graham bill should never get that far. It represents a potentially disastrous step backward, and it’s time to shine more sunlight on it.